Long-term outcome after endoscopic sphincterotomy in patients with biliary colic and suspected sphincter of Oddi dysfunction.

Seventy-three highly selected patients (35 type II, 38 type III) with intractable biliary-type pain were studied with biliary manometry after a baseline endoscopic retrograde cholangiopancreatography was normal or showed only duct dilatation. No differences between the two groups were noted in regard to baseline sphincter hypertension (60% versus 55%), improvement after endoscopic sphincterotomy at mean follow-up of 3 years, or post-procedure pancreatitis rates (15% versus 16%). Although not statistically significant, a tendency for patients with bile ducts > or = 12 mm to have sustained clinical improvement after sphincterotomy was noted in comparison with patients having ducts < 12 mm; an inverse correlation between improvement in symptoms and presence of an intact gallbladder at baseline was also seen. The authors suggest that the current classification, which divides patients with recurrent right upper quadrant pain into types I, II, and III, is inadequate to define either incidence of sphincter of Oddi dysfunction or subsequent response to endoscopic sphincterotomy.

Endoscopic retrograde cholangiopancreatography after laparoscopic cholecystectomy.

We assessed the use of endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic cholecystectomy (LC) at our hepatobiliary referral center. This assessment included patients from outside institutions with post-LC problems. Between May 1990 and September 1992, we performed 522 LCs and 1,723 ERCP examinations. There were 78 patients who underwent 143 ERCP examinations after LC, 65% of whom were referred. ERCP findings were categorized as follows: normal results (8%), problems inherent to stone disease (65%), and iatrogenic injury (27%). The types of inherent problems were common bile duct (CBD) stones, pancreatitis, and papillary stenosis/microlithiasis. Within the CBD stone group, 5 of 26 patients also had papillary stenosis, and, within the pancreatitis group, 9 of 11 patients also had papillary stenosis, making papillary stenosis the most frequent observation (55%). Almost all of these patients (96%) required endoscopic papillotomy for successful treatment. The iatrogenic injury group was comprised of 21 patients, 16% of whom had cystic duct leak and 84% of whom had CBD injury. These patients required a variety of endoscopic procedures including endoscopic papillotomy (67%), CBD endoscopic stenting (76%), percutaneous drainage of biloma (29%), and percutaneous transhepatic biliary drainage (24%). Open surgical procedures after endoscopic assessment or treatment were required in only three patients in the iatrogenic group and in none in the inherent group. At this time, long-term follow-up is not possible with regard to biliary stricture. We conclude that the majority of problems after LC are either due to papillary stenosis/microlithiasis with or without CBD stones or to biliary injury. Both can be successfully diagnosed and treated with endoscopic techniques.

Scintigraphic detection of gastric and pancreatic carcinomas with In-111 ZCE 025 monoclonal antibody.

We have evaluated the role of In-111 anti-CEA (carcinoembryonic antigen) monoclonal antibody ZCE 025 in 8 patients. Three patients had a confirmed diagnosis of gastric carcinoma. Three had a confirmed diagnosis of pancreatic carcinoma. Two patients had elevated serum levels of CEA with no known primary. Each patient received 5.5 mCi In-111 ZCE 025 infused at doses of 10-80 mg. Planar and single photon emission computed tomography (SPECT) imaging at 3 and 7 days after infusion detected 9 of 12 known tumor sites and all 5 of the previously identified sites of metastasis. In-111 ZCE 025 MoAb imaging also found 6 previously unsuspected tumor sites and changed the preoperative evaluation in 50% of the patients studied. It changed the clinical management in 2 patients and established the site of primary involvement in 2 others. There were no clinical or biochemical reactions. In-111 ZCE 025 monoclonal antibody scintigraphy is a useful adjunct in the evaluation of patients with either gastric or pancreatic carcinoma. It may have a beneficial impact on the surgical decision making in these patients.

Colorectal tumors: scintigraphy with In-111 anti-CEA monoclonal antibody and correlation with surgical, histopathologic, and immunohistochemical findings.

A prospective clinical study of 17 patients with a histologic diagnosis of colorectal carcinoma proved at colonoscopy and surgery was performed with indium-111 anticarcinoembryonic-antigen (CEA) monoclonal antibody (MoAb), ZCE-025. MoAb scanning depicted nine of 16 primary colorectal carcinomas on planar scintigrams (true-positive findings = 56%) and ten of 16 lesions on single-photon emission computed tomography (SPECT) scans (true-positive findings = 62%). Liver metastases were detected in three of three patients, and lymph node metastases were detected in one of four patients. Immunohistochemical examination for CEA in resected colorectal cancer tissues demonstrated a positive correlation between MoAb imaging of primary lesions and cytoplasmic-stromal intracellular CEA distribution. There was no correlation between CEA serum levels and lesion detectability with MoAb scanning.

Colorectal carcinoma: detection with indium-111 anticarcinoembryonic-antigen monoclonal antibody ZCE-025.

A phase I and II clinical trial with indium-111-labeled anticarcinoembryonic-antigen monoclonal antibody ZCE-025 (In-111 ZCE-025) was initiated. Fifteen patients with colorectal tumors underwent external scintigraphy following the administration of 5.5 mCi (203.5 MBq) In-111 ZCE-025 at doses of 2.5-80.0 mg. Eighteen of 20 documented tumor sites, excluding those in the liver, were detected with In-111 ZCE-025. Lesions less than 1.5 cm could not be detected. Twenty-five percent of liver metastases exhibited positive accumulation of In-111 ZCE-025 at doses of 40-80 mg. No side effects were encountered. Because of the high detection rate of lymph node metastases from colorectal carcinoma with In-111 ZCE-025, this technique may be helpful in preoperative staging of patients with colorectal tumors, as well as in distinguishing recurrent tumors from postoperative or postradiation changes seen on computed tomography scans or other radiologic images.

An unusual complication of rubber band ligation of hemorrhoids.

Rubber band ligation of hemorrhoids has had a low incidence of complications until recently, when five deaths resulted from bacterial septicemia or toxemia. The case presented describes a severe soft-tissue infection following banding successfully treated with antibiotics, surgical debridement, and hyperbaric oxygen.

Splenic abscess. A rare complication of Crohn's colitis.

This report describes a patient with Crohn's disease of the colon who presented with a rare extraintestinal complication: splenic abscess. Additional features of this case were the association of multiple extraintestinal manifestations of Crohn's disease, including iritis, ankylosing spondylitis, and pericholangitis, and polymicrobial bacteremia. This report emphasizes the cryptic nature of splenic abscess presentation, the more frequent association of extraintestinal manifestations of Crohn's disease with intraabdominal complications, and the association of polymicrobial anaerobic bacteremia with obstructive gastrointestinal complications.